Over the past three decades the application of non-invasive ventilation has emerged as a core therapy in the management of patients with acute and chronic respiratory failure. While the use of NIV in acute respiratory failure was initially confined to the critical care setting it is now well accepted that some patients can be effectively managed in alternative settings where appropriate resources, expertise and staffing are available.

With a rapidly emerging evidence base and the availability of constantly improving ventilator technology, keeping up to date with NIV can be a challenge for many clinicians. In NSW, there is considerable clinical variation between facilities and within facilities for utilisation of NIV and patient outcomes (NSW ICU Practice Audit, 2012). Evidence suggests the use of NIV in the management of acute respiratory failure may:

reduce the need for invasive ventilation

decrease the need for prolonged mechanical ventilation

improve patient outcomes

reduce hospital and ICU length of stay

reduce mortality and morbidity in those with acute on chronic respiratory failure (1, 2).

Guideline

Poster

Initiation and Titration

Interface and Comfort

Purpose

The purpose of this guideline is to provide a consistent level of support and guidance to clinicians in adult critical care areas and specialist respiratory care units about the care required for patients receiving NIV. This guideline draws on current best evidence and clinical expertise and describes key aspects of care including: 1) clinical assessment; 2) NIV management; and 3) and patient care. The guideline does not include recommendations regarding other treatments that patients may require including bronchodilators, cortocosteroids or antibiotics.

The degree to which an adult patient is compliant with NIV not only relates to his or her presenting physiological condition, it also involves a combination of issues associated with the therapy. Primary among these issues is the care required to ensure patient comfort, and thus, compliance. The development of this guideline is to formulate recommendations about best practice (based on evidence and clinical expertise) for the care to be provided to a person receiving NIV. The recommendations apply to patients receiving NIV in rural, regional or urban setting and in any adult critical care or specialised respiratory unit, irrespective of the level of Medical Officer and/or allied health professional support.

Scope

The scope of this guideline is for critically ill adult patients who, following medical assessment, require non-invasive positive pressure ventilation as an adjunct to standard medical therapy. This may occur in intensive care, high dependency and dedicated specialist respiratory units with a higher level of clinical support. It should be noted that this guideline was developed using evidence of best practice relating to adult patients only. The concepts and recommendations may be considered when providing NIV to children.

Target clinicians

This guideline has been developed for all healthcare professionals who provide care for patients with acute respiratory failure who are treated with NIV including nurses, doctors, physiotherapists and other allied health professionals.

How the guideline was developed

A systematic guideline development method (3) was used, based on NHMRC processes and the AGREE tool. A guideline development network (GDN) was formed. This network developed the guideline template that outlined the clinical question and specific areas to be addressed within the guideline. Following this a systematic review was undertaken (for more details see below). The practice review was restricted to a review of local practices from all NSW ICUs. Of the 39 ICUs reviewed, there was a large variance in policies, protocols and practices related to the use of NIV. A technical report was developed from the systematic review and this document was used to inform discussions and recommendation development at the consensus meeting (November 27, 2012).

NHMRC evidence statement forms were used. Following the meeting the guideline document was written and circulated among group members. Consensus development and organisational consultation was undertaken over three stages:

Guideline group consensus - two intensive care doctors were recruited. This larger guideline group received the guideline and technical report. Agreement on recommendations was undertaken using an online survey (Survey Monkey) and a 1-9 Likert scale. Consensus was set as a median of ≥ 7 (see Table 9).

The external validation group received the guideline and technical report. Agreement on recommendations was undertaken using an online survey

Recommendations for practice

level of consciousness (the exception being suitable "do not intubate" unconscious patients with hypercapnic COPD)

anticipated level of compliance with interface

capacity to manage their respiratory secretions and

potential to recover to a quality of life acceptable to the patient.

Failure to meet any one of these criteria renders the patient ineligible for NIV and review of alternate care or escalation of therapy should be undertaken (4, 5).

Consensus

2.

All patients receiving NIV are to have a documented plan of care. This plan is to be developed on commencement of NIV, reviewed on a regular basis (at least every 24 hours and with a change in the patient’s condition) and updated as required. Where available, the care plan is to be developed by a critical care or respiratory Medical Officer or designated clinically qualified respiratory proxy.

Consensus

3.

All patients receiving NIV are to have a formal assessment and documentation of full body skin integrity at least daily. This includes the skin under the interface i.e. nose, face and neck.

Assessment of mask fit, interface type, head strap tightness, skin integrity of mask contact point, ventilation synchrony and degree of mask leak are to be completed each time the interface is adjusted and at least second hourly (6, 7).

Consensus

5.

Interventions to prevent pressure injury secondary to the interface are to be implemented on commencement of NIV.

Consensus

6.

When deterioration in skin integrity is identified, immediate strategies are to be employed to reduce further injury (6).

A clear plan for the parameters indicating escalation to intubation and ventilation in the event of NIV failure is to be documented on clinical presentation or initiation of therapy (6).

Consensus

19.

If the patient does not clinically improve within four hours of starting NIV the decision to intubate and ventilate is to be made (6).

A

20.

Intubation and ventilation is to be implemented rather than NIV continued for late failure (where late failure is defined as failure after 48 hours of NIV) (6).

B

21.

A clear plan for the parameters indicating the decision not to intubate and ventilate in the event of NIV failure is to be documented on clinical presentation or initiation of therapy. This decision is to be discussed between the patient (or enduring guardian) and treating medical specialist and documented in the clinical records (6).

Consensus

22.

An advanced health directive is to be completed for any future presentations if one has not previously been completed (13).

Palliation for symptom relief, in combination with opioids and benzodiazepines, to treat breathlessness is to be documented on clinical presentation or initiation of therapy by medical staff. Such plans are to be implemented by nursing staff in response to assessment of patient comfort as required (6).

to be asked if they have a current advanced health directive prior to the implementation of NIV. A significant other may provide evidence of any directives and should be included in this conversation.

Patients who do not have a current advanced health directive are to be provided with information relating to advanced care planning as part of an integrated care plan for management of their wishes for end-of-life care, once they are clinically stable (13).

A clear plan for the nursing care to be provided while the patient is receiving NIV is to be documented within 24 hours of initiation of therapy. This plan is to include the psychosocial support including (but not limited to) cultural safety, spiritual needs, family needs and financial concerns.

Consensus

26.

Oral hygiene is to be attended every two hours as long as the patient’s tolerance to ceasation of NIV is longer than five minutes. Refer to the Oral Care Clinical Practice Guideline for further information.

Consensus

27.

Eye care is to be attended every two hours. Refer to the Eye Care Clinical Practice Guideline for further information.

Eye Care Clinical Practice Guideline

28.

A full body wash, including facial shave, is to be attended daily or more often as required in response to patient diaphoresis and the patient’s level of tolerance..

Consensus

29.

Patients are to receive pressure injury prevention management as per the Pressure Injury Prevention Guideline.

Pressure Injury Prevention Guideline

30.

Patients are to be encouraged to sit out of bed as tolerated. When in bed they are to be positioned in an upright position to facilitate chest wall expansion.

Pressure Injury Prevention Guideline

31.

The Physical Activity and Movement Guideline provides a graded mobility schedule. Patients are to be assessed and managed as per this guideline.

Physical Activity and Movement Guideline

32.

Pharmacotherapies (i.e. anti-anxiolytics) are to be documented by medical staff on clinical presentation or initiation of therapy and implemented by nursing staff as required in response to patient assessment (6).

Consensus

33.

Referrals to allied health professionals are to be implemented where services are available in the clinical setting to support the patient and his or her significant other/s psychosocial wellbeing.

Oral feeding is to be initiated if the patient is able to tolerate small periods off NIV.

Consensus

35.

No oral intake is to be implemented if the patient has a decreased LOC or the patient is in respiratory distress with an increased work of breathing (i.e. R.R > 30/min). Intravenous fluids are to be commenced in these circumstances.

Consensus

36.

Patients receiving NIV are to have daily UECs and CMP blood samples taken for the duration of their NIV therapy to assess fluid and electrolyte status (6).

Consensus

37.

Patients receiving NIV are to have a strict fluid balance and stool chart implemented for the duration of their NIV therapy to assess elimination and fluid status.

Consensus

38.

Dietetics and nutritionist assessments are to be undertaken and documented for the patient receiving NIV 24 hours after initiation of therapy.

Clinicians are to undertake a risk assessment to identity the risk of contamination and mucosal or conjunctival splash injuries when caring for a patient being treated with NIV. PPE (including goggles/face shield/gloves and gown/apron) as per NSW 2007 Infection Prevention Control Policy should be worn according to the risk assessment (14, 15).

PD2007_036 Australian Guidelines for Prevention & Control of Infection in Healthcare.

40.

Clinicians must adhere to the Five Moments of Hand Hygiene (16).

PD2010_058

41.

To reduce the risk of microbial transmission, equipment utilised for each patient must be cleaned as per the NSW Infection Control Policy and ASA Standard 4187 prior to and following use (14, 17).

PD2007_036

AS 4187 2003

42.

Items labeled single patient use are intended to be used in the care of one patient only and are to be discarded when the patient no longer requires the item (14).

NSW Policy PD 2007_036

43.

Reuse of an NIV circuit/face mask may be possible only if the items are marked as reuse and cleaning instructions are supplied; the manufacturer’s recommendations are to be followed. The NSW Infection Control Policy (PD2007_036) states that the circuit and face mask are classified as a semi-critical item and require cleaning and disinfection before reuse (14).

Any health facility that provides NIV should have a policy/procedure stating patient selection criteria and management plan/s for patients recovery, NIV including initial settings and escalation strategies (18).

Consensus

45.

The frequency of documentation for NIV is to be at least hourly in the acute phase and then may be reduced to 2-4 hourly once the patient is stable or is in a specialised respiratory unit.

Consensus

46.

Patients receiving NIV must be located in a ward area where there are appropriate numbers of competent staff able to provide monitoring and titration of therapy consistent with all aspects of patient care required.

Consensus

47.

Organisations providing NIV are to have formal education processes relating to NIV and a competency assessment package for new graduates and staff working in these areas.

Consensus

48.

Where hospitals wish to monitor the outcomes of patients receiving NIV, minimum data for collection could include:

Patient outcome (survival/death)

ICU and or specialist ward and hospital LOS

Length of ventilation

Treatment complications

Machine used and settings

Clinical data (diagnosis, PaO2, PaCO2)

Quality of life assessment/EOLCP

Dyspnoea scores (Borg)

Consensus

The evidence review for these recommendations was current to December 2012. Clinicians are advised to check the literature as research may have been published that change these recommendations.

Grading of recommendations

Grade of recommendation

Description

A

Body of evidence can be trusted to guide evidence

B

Body of evidence can be trusted to guide practice in most situations

C

Body of evidence provides some support for recommendation/s but care should be taken in its application

D

Body of evidence is weak and recommendation must be applied with caution

Disclaimer

The information on this page is general in nature and cannot reflect individual patient variation. It reflects Australian intensive care practice, which may differ from that in other countries. It is intended as a supplement to the more specific information provided by the doctors and nurses caring for your loved one. ICNSW attests to the accuracy of the information contained here but takes no responsibility for how it may apply to an individual patient. Please refer to the full disclaimer.